Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on January 20, 2021, at Elwyn Of Pennsylvania And Delaware - Chichester, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - ELWYN CHICHESTER AVE Component - 01
Facility ID# 20881101
Component 01
Based on a Medicaid Recertification Survey completed on January 20, 2021, it was determined Elwyn of Pennsylvania and Delaware-Chichester Avenue was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID Health Care Occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a one-story, Type V (000), unprotected wood frame structure, with a basement, which is fully sprinklered.
State plans approved as Prompt.
Plan of Correction:
NFPA 101 STANDARD
Operating Features - Other
Name - ELWYN CHICHESTER AVE Component - 01
Operating Features - Other
List in the REMARKS section any LSC Section 32.7 and 33.7 Operating Features requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Based on document review and interview, it was revealed the facility failed to maintain means of egress free of obstructions or impediments to full instant use in case of fire or other emergency as required by NFPA 101, 7.1.10.1, affecting the entire component.
Findings include:
1. Document review on January 20, 2021, between 8:15 a.m. and 10:00 a.m., revealed the facility was unable to produce a snow removal policy.
Interview at the exit conference with the Director of Maintenance and Operations Manager on January 20, 2021, at 10:25 a.m., confirmed the missing documentation.
Plan of Correction:A copy of the snow removal plan was located by Maintenance and placed in the Emergency Preparedness Plan binder on 1/22/21. Elwyn contracts with a company that provides snow removal to Chichester which includes: plowing drives, shoveling sidewalks, clearing ramps and salting. If the parameters of the snow removal plan changes, Maintenance is responsible for providing the residence and Quality Improvement Department a copy of the updated plan.
A monthly meeting has been scheduled between the Director and Associate Director of Quality Improvement, with a reminder placed on the outlook calendar to review the Emergency Preparedness Plan monthly and update accordingly.
The Director of Quality Improvement will be responsible for monitoring this corrective action. DOC: 2/1/21
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